*NURSING > SOAP NOTE > NR-509 Week 4 Cardiovascular SOAP Note (RATED A) (All)

NR-509 Week 4 Cardiovascular SOAP Note (RATED A)

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SOAP Note Template Initials: TJ Age: 28 Gender: Female Height Weight BP HR RR Temp SPO2 Pain Allergies 170cm 88kg 139/ 87 82 16 98.9F 99% Medication: Penicillin (rash/ hives) Food:... none Environment: Cats, dust (asthma flares up, itchy, watery eyes, sneezing) History of Present Illness (HPI) Chief Complaint (CC) Headache CC is a BRIEF statement identifying why the patient is here - in the patient’s own words - for instance "headache", NOT "bad headache for 3 days”. Sometimes a patient has more than one complaint. For example: If the patient presents with cough and sore throat, identify which is the CC and which may be an associated symptom Onset 5 days ago Location Pain is located at the crown and back of head. Duration Intermittent- daily-lasts for 1-2hrs per episode. Characteristics Dull headache, non- radiating, associated with neck pain Aggravating Factors Movement of head Relieving Factors Tylenol- improved pain to 3/10 ,rest Treatment No other treatment Current Medications: Include dosage, frequency, length of time used and reason for use; also include OTC or homeopathic products. Medication (Rx, OTC, or Homeopathic) Dosage Frequency Length of Time Used Reason for Use Proventil 2 puffs PRN for asthma PRN Rescue inhaler for asthma exacerbation Flovent Patient unaware of exact dosage BID Daily Mainenence for Asthma Tylenol 2- regular strength tabs Once a day Once a day for 5 days For headache Advil 200mg PRN PRN For menstrual cramps N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Past Medical History (PMHx) – Includes but not limited to immunization status (note date of last tetanus for all adults), past major illnesses, hospitalizations, and surgeries. Depending on the CC, more info may be needed. Should include: the accident MVA, should pertain to the Chief complaint, 15mile accident in parking lot, wearing seat belt, rear end fender bender. Was not drinking alcohol. (Asthma dx age 2.5 yrs old, Diabetes dx at 24yrs old, Denies surgical history, last hospital admission at 16 yrs old for asthma exacerbation. Reports all Immunization are current at this visit, Last Flu vaccine: 5 or 6 years ago per patient, declines at this time Last Tetanus booster: two years ago Reports Meningitis Vaccine at 19yrs old. Social History (Soc Hx) - Includes but not limited to occupation and major hobbies, family status, tobacco and alcohol use, and any other pertinent data. Include health promotion such as use seat belts all the time or working smoke detectors in the house. Supervisor at Mid-American Copy & Ship, Bachelor’s accounting student, Hobbies:Reading, watchingTV, hanging with friends and going to church. Close with mother and sister (living together), Brother lives with fiancee, father deceased from car accident. Denies tobacco use. Alcohol use socially with friends ( rum and diet coke drink of choice). Drives and always uses a seatbelt, working smoke detector in house. Family History (Fam Hx) - Includes but not limited to illnesses with possible genetic predisposition, contagious or chronic illnesses. Reason for death of any deceased first degree relatives should be included. Include parents, grandparents, siblings, and children. Include grandchildren if pertinent. Mother- high cholesterol and hypertension Father (deceased at 58 car accident 2 years ago)- Hx of Diabetes, high cholesterol and hypertension Brother 25 y.o.- Obesity Sister 14 yrs old- dx age 2 or 3 with asthma. maternal grandma- HTN and high cholesterol maternal grandpa-HTN and high cholesterol. paternal grandma-HTN and high cholesterol paternal grandpa- (deceased) colon cancer, HTN, diabetes. Review of Systems (ROS): Address all body systems that may help rule in or out a differential diagnosis Check the box next to each positive symptom and provide additional details. Constitutional Skin HEENT ☐ Fatigue Denies ☐ Weakness Denies ☐ Fever/Chills Denies ☐ Weight Gain Denies ☐ Weight Loss Denies ☐ Trouble Sleeping Denies ☐ Night Sweats Denies ☐ Other: ☐ Itching Denies ☐ Rashes Denies ☐ Nail Changes Denies ☐ Skin Color Changes Denies ☐ Other: Click or tap here to enter text. ☐ Diplopia Denies ☐ Eye Pain Denies ☐ Eye redness Denies ☒Vision changes blurry when does a lot of reading ☐ Photophobia Denies ☐ Eye discharge Denies ☐ Earache Denies ☐ Tinnitus Denies ☐ Epistaxis Denies ☐ Vertigo Denies ☐ Hearing Changes Denies ☐ Hoarseness Denies ☐ Oral Ulcers Denies ☐ Sore Throat Denies ☐ Congestion Denies ☐ Rhinorrhea Denies ☐ Other: Click or tap here to enter text. Click or tap here to enter text. Respiratory Neuro Cardiovascular ☐ Cough denies ☐ Hemoptysis denies ☐ Dyspnea denies ☐ Wheezing denies ☐ Pain on Inspiration denies ☐ Sputum Production ☐ Other: Click or tap here to enter text. ☐ Syncope or Lightheadedness denies ☒Headache reports tension ☐ Numbness denies ☐ Tingling denies ☒Sensation Changes ☐ Speech Deficits denies ☒Other: denies sensation changes ☐ Chest pain denies ☐ SOB denies ☐ Exercise Intolerance denies ☐ Orthopnea denies ☐ Edema unable to assess ☐ Murmurs unable to assess ☐ Palpitations unable to assess ☐ Faintness unable to assess ☐ OC Changes denies ☐ Claudications denies ☐ PND denies ☐ Other: Click or tap here to enter text. MSK GI GU PSYCH ☐ Pain denies ☒Stiffness reports neck stiffness ☐ Crepitus unable to assess ☐ Swelling denies ☐ Limited ROM ☐ Redness denies ☐ Misalignment denies ☐ Other: Click or tap here to enter text. ☐ Nausea/Vomiting denies ☐ Dysphasia denies ☐ Diarrhea denies ☐ Appetite Change denies ☐ Heartburn denies ☐ Blood in Stool denies ☐ Abdominal Pain denies ☐ Excessive Flatus denies ☐ Food Intolerance denies ☐ Rectal Bleeding denies ☐ Other: Click or tap here to enter text. ☐ Urgency denies ☐ Dysuria denies ☐ Burning denies ☐ Hematuria denies ☐ Polyuria denies ☐ Nocturia denies ☐ Incontinence denies ☐ Other: Click or tap here to enter text. ☐ Stress denies ☐ Anxiety denies ☐ Depression denies ☐ Suicidal/Homicidal Ideation denies ☐ Memory Deficits denies ☐ Mood Changes denies ☐ Trouble Concentrating denies ☐ Other: Click or tap here to enter text. GYN ☐ Rash denies ☐ Discharge denies ☐ Itching denies ☒Irregular Menses reports almost two months between periods ☐ Dysmenorrhea denies ☐ Foul Odor denies ☐ Amenorrhea denies ☒LMP: started a few days ago ☐ Contraception Denies taking for 3 yrs now ☐ Other:Click or tap here to enter text. Body System Positive Findings Negative Findings General Skin Click or tap here to enter text. Decreased sensation of bilateral feet and inspected skin darkening on the neck. Patient is alert and oriented, pleasant. normal stature while sitting on the exam table, dressed appropriately, and well groomed. In no acute distress and maintains eye contact during examination. Neg inspection for wounds, rash, or lesions HEENT Respiratory Visual acuity: Right eye is 20/40 and Left eye is 20/20. Click or tap here to enter text. Needed to add, the fundoscopic exam- positive for cotton wool bodies. Neg for Papilledema. Head: no trauma, round, and normocephalic. Ears- intact no hearing issues. Pupils are equal, round, and reactive to light. Nose: sense of smell intact, sense of taste: intact, Respirations are 16, patient chest rise symmetrical, no respiratory distress noted, patient spo2 =99% on room air. Neuro Cardiovascular Decreased sensation in bilateral feet (bottom soles) Click or tap here to enter text. Abstract thinking, attention span, comprehension,general knowledge, judgment, memory, vocabulary, articulation, 12 cranial nerves, optic and oculomotor nerves, extraocular eye movements, weber test, Rinne test, gait, graphesthesia, stereognosis all within normal limits. Click or tap here to enter text. Musculoskeletal Click or tap here to enter text. Gait is balanced and normal. Gastrointestinal Click or tap here to enter text. Click or tap here to enter text. Genitourinary Click or tap here to enter text. Click or tap here to enter text. This study source was downloaded by 100000849840424 from CourseHero.com on 11-16-2022 07:58:33 GMT -06:00 A: Assessment Medical Diagnoses. Provide 3 differential diagnoses which may provide an etiology for the CC. The first diagnosis (presumptive diagnosis) is the diagnosis with the highest priority. Provide the ICD-10 code and pertinent findings to support each diagnosis. Diagnosis ICD-10 Code Pertinent Findings Headache Correct one: post-traumatic headache is the correct diagnosis R 51 Patient complains of 3 out of 10 headache pain at the crown and back of head Correct: pos MVA, Neck pain M54.2 Patient c/o neck soreness after a car accidnet Neck strain S16.1XXA Patient c/o neck stiffness after a car accident. P: Plan DAidadgrensossatillc5s:paLritsst otef sthtse ycoomu pwreillhoerndseivrethtriesavtmiseitnt plan. If you do not wish to order an intervention for any part of the treatment plan, write “None at this timeT” ebsut do not leave any heading blank. No intervention is self-evidentR. Patriovniadle /aCritattiionale and evidence-based in-text citation for Ne/aAchuninletesrsvseynmtiopnto. ms unresolved by follow up appointment. According to Wang & Yeh (2019), CT is used if <72hrs of trauma, for suspected intracranial bleed. No fever associated, headache pain reported is not severe and does not escalate. N/A Click or tap here to enter text. N/A Click or tap here to enter text. N/A Click or tap here to enter text. N/A Click or tap here to enter text. Medications: List medications/treatments including OTC drugs you will order and “continue previous meds” if pertinent. Drug Dosage Length of Treatment Rationale/Citation Acetaminophen Don’t give muscle relaxer (dangerous) 650mg Every 6hrs PRN Headache Is the lowest cost recommended treatment for acute headache (Papadakis, McPhee, & Bernstein, 2019). Continue home meds Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. N/A Click or tap here to enter text. Click or tap here to enter text. Click or tap here to enter text. Referral/Consults: Refer to an opthamologist Rationale/Citation Patient complains of blurry vision and headaches when reading or studying. Snellen eye chart results show that right and left eye visual acuity differs (Goadsby et al, 2019). Education: Due to a normal neurological exam, and a dull headache pain that does not escalate and relieved by OTC Tylenol, I will educate patient to continue headache treatment with Tylenol and to follow up if symptoms worsen. Rationale/Citation Tylenol for treatment for acute headache (Papadakis, McPhee, & Bernstein, 2019). Follow Up: Indicate when patient should return to clinic and provide detailed instructions indicating if the patient should return sooner than scheduled or seek attention elsewhere. Follow up at the clinic in 1 week if not better. If symptoms of headache worsen or sever headache, call 911 in case of an emergency and seek medical attention. Rationale/Citation According to Goadsby, et al., (2019), after treatment has been initiated, follow-up care is essential to identify whether progress has been made against the headache complaint. References Include at least one evidence-based peer-reviewed journal article which relates to this case. Use the correct APA 6th edition formatting. Goadsby PJ, Jameson J, Fauci AS, Kasper DL, Hauser SL, Longo DL, Loscalzo J. (2019). Harrison's principles of internal medicine: Headache, 20ed. New York, NY: McGraw-Hill. Retrieved from: http://accessmedicine.mhmedical.com.chamberlainuniversity.idm.oclc.org/content.aspx? bookid=2129&sectionid=192011003. Maxine A. Papadakis, Stephen J. McPhee, Jennifer Bernstein. (2019). Quick Medical Diagnosis & Treatment: Headache, acute New York, NY: McGraw-Hill. Retrieved from: http://accessmedicine.mhmedical.com.chamberlainuniversity.idm.oclc.org/content.aspx? bookid=2566&sectionid=206884926. Accessed September 21, 2019. [Show More]

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